Nevada’s ‘Medicaid for All’ Bill, the First Single-Payer Plan, Is Vetoed

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After days of suspense, Nevada’s Republican governor Brian Sandoval late Friday vetoed a trailblazing law that would have allowed any of the state’s 2.9 million residents to purchase Medicaid, the state-run federal health insurance for the poor, irrespective of income levels, age or health status.

The bipartisan “Medicaid for All” legislation – the first of its kind in the nation -- passed the Democratic-controlled state legislature earlier this month but remained in limbo while Sandoval deliberated over whether to sign it, veto it or allow it to automatically take effect midnight Friday.

Had he allowed the legislation to take effect, the former federal judge would have emerged as a leading advocate for preserving the nation’s premier health plan for low-income and disabled people and expanding it as a single-payer government option for all Nevada residents. Essentially, anyone could acquire Medicaid-style coverage on the open market provided he or she could pay a relatively modest premium. The single-payer option has long been a dream of many liberal and moderate Democrats and was considered during the prolonged debate over the 2010 Affordable Care Act.

While praising the Democratic “Medicaid for All” legislation sponsored by Assemblyman Michael Sprinkel, Sandoval said he ultimately concluded that there were too many unanswered questions about how the program would work.

The governor wrote that the bill was “an undeveloped remedy to an undefined problem” and that it hadn’t received proper scrutiny before it was passed in a short time frame.

Indeed, the bill was remarkably brief – just four pages long – and Sprinkle acknowledged that there were many unanswered questions as to how the program would be put into effect.

The plan – called the Nevada Care Plan -- would have likely been sold on the state-run health insurance exchange, making it competitive with private health insurance plans. Advocates said it would provide an inexpensive alternative to private individual health insurance and a broad range of benefits nearly identical to those under traditional Medicaid.

However, there were numerous obstacles and stumbling blocks to getting the program up and running by January 2019, the target date for the start-up. The bill required Nevada officials to obtain permission from the Department of Health and Human Services to move ahead with the plan, but with no guarantee, the Trump administration, which favors rolling back Medicaid, would go along with the experiment.

The sketchy bill provided no hint of how much the new program would cost the state and the federal government, or how much the premiums and related copayments might cost – although presumably far less than market rate coverage.

Also, media reports say many health care providers, including the Nevada Hospital Association, were worried about the Nevada Care Plan reimbursing them at lower rates than private individual insurance plans pay. There were also concerns among insurers that the new plan would further disrupt an already unstable health care insurance market.

In many states, doctors, hospitals, and even pharmacies have dropped out of Medicaid altogether because of the low reimbursements that they say are unsustainable for their institutions and businesses.

Sandoval’s decision comes at a time when the Trump administration and congressional Republicans are considering major changes to the Medicaid program as part of legislation to repeal and replace the Affordable Care Act.

A House-passed version of the GOP proposals would roll back expanded Medicaid for low-income, able-bodied, childless adults; cut overall Medicaid funding by more than $800 billion over the coming decade; and shift to a per-capita capped block grant system of federal funding of Medicaid that could result in millions of people being forced from the rolls.

Sandoval, a moderate Republican and the first Hispanic to have won a statewide office in Nevada, has been a champion of the Affordable Care Act from the start.

Sandoval, the first Hispanic Governor of Nevada and a champion of the Affordable Care Act from the start, was one of 16 Republican governors of states that opted for expanded Medicaid, which added 200,000 Nevadans to 400,000 already enrolled in Medicaid.

Early last week, Sandoval parted company with Nevada Republican Sen. Dean Heller, who is supporting a proposal in the Senate to gradually phase out the expanded Medicaid program over seven years. “It’s working --we have brought down our uninsured rate,” Sandoval said in formally opposing the Senate GOP phase-out proposal.

Then on Friday, Sandoval took another step in trying to preserve the Medicaid program. He was one of seven Republican and Democratic governors to sign a letter urging Senate Majority Leader Mitch McConnell (R-KY) to abandon a highly secretive GOP effort to ram Obamacare replacement legislation through the Senate before the August recess.

Instead, Sandoval, GOP Gov. John Kasich of Ohio and the five other governors wrote that Congress should seek a bipartisan solution that spares low-income Americans from deep cuts in Medicaid coverage. They proposed an overhaul of Obamacare that focuses on stabilizing the individual insurance markets, giving states flexibility and ensuring affordable coverage.

In his veto message Friday night, Sandoval said that his opposition to Sprinkel’s bill “does not end the conversation about potential coverage gaps or possible solutions, including Medicaid-like solutions.”

“Given the possibility that changes in federal law may put Nevada’s expanded Medicaid population at risk of losing their coverage, the ability for individuals to purchase Medicaid-like plans is something that should be considered in depth,” Sandoval wrote. “If done correctly, the [Medicaid for All] proposal could provide a necessary safety net for those who may no longer have access to traditional Medicaid.”

Washington Editor and D.C. Bureau Chief Eric Pianin is a veteran journalist who has covered the federal government, congressional budget and tax issues, and national politics. He spent over 25 years at The Washington Post.